Download Highlights from the COPD Foundation COPD7usa Conference

Highlights from the COPD Foundation
COPD7usa Conference
Byron Thomashow,
M.D.
Jo-Ann LeBuhn
Center for Chest
Disease,
New York
Presbyterian Hospital
New York, New York
Barbara P. Yawn,
MD, MS, FAAFP
University of
Minnesota,
Minneapolis, MN.
Fabiana Talbot,
COPD Foundation
The COPD7USA conference featured 3 tracks to address specific areas of interest for
each learner. Tracks included Clinical, Research, and Care Delivery options. The next 2
articles highlight the Care Delivery and Research Tracks. For audio of sessions
presented at COPD7usa, please visit the conference website:
www.copdconferencesusa.org.
he COPD7usa Care Delivery track featured 4
sessions: Care Delivery, 2-Transitions of Care,
3-Comparative Effectiveness Research, 4Care Payment.
T
Dr. Barbara Yawn, family physician from the
Olmsted Medical Center and University of
Minnesota moderated the first delivery of care
session. Joining her to present two illustrative
individual cases was pulmonologist Dr. Antonio
Anzueto from the University of Texas at San
Antonio, respiratory therapists and educators
Gerilynn Connors, BS, RRT, FAACVPR from Inova
Fairfax Hospital, and Jane Martin, BA, LRT, CRT
from the COPD Foundation. The first case
illustrated the broad support required to
introduce a person with newly diagnosed COPD
to the disease, their medications and future
expectations. Dr. Yawn pointed out that most
patients are diagnosed during or shortly after an
exacerbation and therefore only ready for
limited education and early return visit(s). Dr.
Anzueto recommended that diagnostic
spirometry may have to be delayed for 6 to 12
weeks to obtain an accurate baseline of COPD
severity. Both Ms. Connors and Martin
suggested help from respiratory therapists to
teach and follow up on inhaler technique and
provide basic education which could be done at
the follow up visit for spirometry. All
participants agreed that initial messages need
to be simple and straightforward, emphasizing
how, when and why to use medications and the
importance of regular return visits. Of course
smoking cessation must be part of every visit for
anyone continuing to smoke.
The panel went on to discuss the need for
metrics to assess the effect of medical therapy,
the decision when the patient has recovered
from the exacerbation sufficiently to attend
28 LUNG HEALTH PROFESSIONAL MAGAZINE • VOLUME 3 I NUMBER 1 I 2012
pulmonary rehabilitation, and when to enhance
medication treatments. Spirometry may or
may not improve with therapy, but is useful to
help patients see the impact of its use. The six
minute walk test may be useful to demonstrate
improved functional status. The COPD control
test may be helpful in determining when
additional treatment is needed. Of course
counting exacerbation also works, but all panel
members preferred to be able to prevent
exacerbations rather than wait for the next one
as a marker of treatment failure.
For patients with confusing spirometry, such as
a combined restriction and obstruction pattern
referral for full pulmonary function testing from
an experienced RT, an interpretation and
consultation from a pulmonologist is needed.
The ideal setting is one in which the respiratory
therapist, COPD educator, the primary care
physician and a consulting pulmonologist can
interact to provide the person with COPD (and
their family) the medical home that they need.
Realizing the strengths and limitations of each
health professional and their setting can
improve their ability to focus care on the patient.
Respect for each individual member of the team
comes from this working together across care
sites and disciplines. Learning when, where
and how to ask for help and support is not
limited to the patient and their family but a task
for all health professionals when working to
improve the lives of people with COPD.
Dr. Jerry Krishnan chaired the Comparative
Effectiveness Research Session and was joined
by Dr. Joe Selby of the Patient-Centered
Outcomes Research Institute; Dr. Tony
Punturieri of the National Heart, Lung, and
Blood Institute; and John Walsh of the COPD
Foundation.
Dr. Krishnan initiated the session and discussed
the role of comparative effectiveness research
(CER) in COPD. Refinements to clinical trials in
the past 250 years have increased the ‘signal to
noise’ ratio, which has affected participant
selection, randomization of treatment
allocation, research infrastructure, and overall
planning. Efficacy trials are likely to have great
direct benefits, utilize practice settings with low
rates of complications, and have specific yet
costly experimental intervention. However,
they may exclude many, if not most, real-world
patients, as research conditions do not mimic
delivery of care in clinical settings.
Conversely, comparative effectiveness research
(CER) synthesizes the benefits and harms of
different interventions in real world settings.
CER improves health outcomes by developing
and disseminating evidence-based information
to patients, clinicians, and other decisionmakers by responding to their expressed needs.
These considerations determine which
interventions are most effective for specific
patients and circumstances. CER is
underdeveloped in the U.S. and needs
infrastructure to support collaboration
between stakeholders who generate,
disseminate, and use new knowledge.
Continued involvement of stakeholders is
required to ensure the validity, feasibility,
timeliness, and relevance of study protocols.
CER is also utilized to determine Medicare
coverage and reimbursement. When Medicare
decides to cover a new healthcare item or
service, evidence of superior comparative
clinical effectiveness determines usual pricing
(payment based on existing formulas). It also
provides evidence of comparative clinical
effectiveness, or reference pricing (payment
equal to that for equality effective alternative).
Insufficient evidence to judge comparative
clinical effectiveness leads to dynamic pricing
(payment based on existing formulas, with
effectiveness reevaluated after three years).
Dr. Selby discussed The Patient-Centered
Outcomes Research Institute’s (PCORI) role in
developing national priorities and research
agenda related to COPD. PCORI’s purpose in
defining legislation:
“Assist patients, clinicians, purchasers, and
policy-makers in making informed health
decisions by advancing the quality and
relevance of evidence…[relevant to] the manner
in which diseases, disorders and other health
conditions can effectively and appropriately be
prevented, diagnosed, treated, monitored, and
managed through research and evidence
synthesis.” (Affordable Healthcare Act, 2010)
To ensure research outcomes remain patientcentered, studies must understand the choices
patients face through patient engagement,
align research questions and methods with
patient needs, and provide patients and
providers with information for better decisions.
Patient-centered outcomes research is
considered CER as it incorporates the patient
voice to ensure research questions are practical,
outcomes are important to patients are
identified, those studied are representative of
those who require information from specific
settings, and heterogeneity in effectiveness is
carefully examined. Frequently cited priority
areas include: prevention and screening; acute
care; chronic disease care; palliative care and
pain management; care coordination; patient
engagement; and health information
technology. PCORI’s national research priority
areas draw from the frequently cited areas, and
frame five draft national priorities:
implementing comparative clinical
effectiveness, improving healthcare systems,
streamlining communication and dissemination,
improving fairness/addressing disparities, and
accelerating patient-centered research.
Dr. Punturieri, Program Director of the Division
of Lung Diseases at the National Heart, Lung
and Blood Institute (NHLBI), discussed the role
of CER in lung research. Accurate, timely data
remains a constant need in the field; nearly 50%
of recommendations are based on expert
opinion, yet 11% are based on multiple
randomized trials. Effective CER requires full use
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of broad range of study designs, utilizing
observational studies to conduct CER and for
needs assessment, encourage researchers to
collect information on a range of outcomes,
promote interest in CER among the scientific
community, increase efforts to engage
stakeholders, and invest in development of
databases and infrastructure supporting CER.
As an individual with Alpha-1 related genetic
COPD and founder of the COPD and Alpha-1
Foundations, Mr. John Walsh concluded with
insights on CER from the patient perspective.
Patients’ two main priorities are survival and
quality of life, with serious concerns about costs
associated with multiple co-morbidities and
medications. He explained that a clear
distinction of “comparative effective” versus
“cost effectiveness” research must be made to
the patient. The CER process must be
transparent, involving all stakeholders in the
research process to enhance the credibility of
studies. For research to be clinically meaningful,
it must impact one’s quality of life, family life,
and functional capacity. When studies focus on
the totality of healthcare delivery system, they
are more likely to improve health outcomes.
This requires researchers to go beyond drugs
and biologics and into prevention services,
diagnostic tests, medical procedures, and
health management programs.
Dr. Robert Sandhaus chaired the “Addressing
Cost of COPD” session, and was joined by Dr.
Tangita Daramola of Competitive Acquisition
Ombudsman Group; and Drs. Howard Garber
and Scott Berkowitz of Johns Hopkins
University School of Medicine.
Dr. Sandhaus reviewed the roll that a well
designed and effectively administered Health
Maintenance/Disease Management can play
in reducing the cost of COPD. He presented
the Alpha-1 Disease Management and
Prevention Program (ADMAPP) and reviewed
the outcome data documenting its
improvement in healthcare utilization and
quality of life for participants.
Alpha-1 Antitrypsin Deficiency (AATD) is the
major genetic cause of COPD. AlphaNet, a notfor-profit health management organization,
developed ADMAPP as a way to improve the
lives and reduce the healthcare costs for its 3,000
30 LUNG HEALTH PROFESSIONAL MAGAZINE • VOLUME 3 I NUMBER 1 I 2012
members with AATD. The ADMAPP program
centers on the patient-aimed Big Fat Reference
Guide to Alpha-1 (the BFRG) and includes nurse
training and certification, telephonic
coordination of patient education and follow-up,
and continuous monitoring of patient outcomes.
The disease management coordinators who
each follow between 100 and 150 patients are all
patients with AATD themselves.
The program has been functioning since 2003
and outcome data has confirmed that patients
in the program has seen a reduction in their
healthcare utilization including decreased ER
visits, decreased hospitalizations, decreased
physician visits, decreased frequency and
severity of exacerbations, and decreased
steroid and antibiotic usage. At the same time
they have demonstrated a stabilization of their
quality of life, both in terms of general health
and respiratory-specific measurements.
Dr. Daramola discussed issues related to
Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) competitive
bidding program and the Competitive
Acquisition Ombudsman (CAO). The Medicare
Competitive Acquisition Ombudsman was
created in an effort to support the Competitive
Bidding Program in responding to individual
and supplier inquiries, issues, and complaints. It
is also responsible for reporting to Congress
annually. The DMEPOS Medicare program
reduces out-of-pocket expenses for
beneficiaries, saves the Medicare program
while ensuring beneficiaries quality products
and qualified suppliers. CAO core functions
promote fairness and access by responding to
suppliers’ and beneficiary complaints and
inquiries regarding DMEPOS Competitive
Bidding Program; communicating with
Congress by providing an annual report that
details CAO activities; identifying potential
challenges to successful implementation and
offer mitigation strategies; and facilitate
understanding through regular communication
with partner organizations.
Dr. Garber’s presentation addressed a pressing
issue currently among the most discussed in
COPD – the effort to decrease re-hospitalization
following an admission with a COPD
continued on page 32
continued from page 30
exacerbation. He presented the data obtained
from the Johns Hopkins Medical Center
regarding efforts to address the issues that lead
to readmission. After reviewing the identified
issues that are associated with early readmission,
he discussed the benefits of a COPD Home
Health Care Clinical Pathway approach to
addressing and resolving these issues.
Dr. Berkowitz, Medical Director for Accountable
Care at Johns Hopkins University, described
chronic conditions and their associated costs.
The total U.S. annual cost of COPD is $40 billion.
Americans living with chronic conditions will
increase by 46 million between 2000 and 2030,
with 4x greater healthcare costs per condition
and 25x greater costs with five or more. He
described the Affordable Care Act (ACA) as a
framework for improving care by: expanding
coverage; reducing federal deficit; emphasizing
quality; reducing fraud and waste; funding
comparative effectiveness research; reducing
burdensome paperwork; and focusing on
prevention and wellness. He went on to explain
the ACA’s role in promoting ACOs, a providerbased arrangement where the providers are
accountable for the quality, cost and overall care
of a set of patients. ACOs organize and
coordinate the end-to-end delivery of services
for each participant across the care continuum.
Dr. Byron Thomashow chaired the Transitions of
Care track; he was joined by Dr. Richard Cassaburi
from. Harbor-UCLA Medical Center, Dr. Ravi
Kalhan from Northwestern University, Dr. Jill Ohar
from Wake Forrest University, and Dr. Scott
Conard from ACAP Health and GOH Medical.
Dr. Thomashow began the discussion by
reviewing the increasingly important issue of
hospitalizations and re-hospitalizations. The cost
of COPD care in this country now stands at
almost 50 billion dollars a year: almost 70% are
due to care related to exacerbations, mostly
reflecting cost for hospitalizations. Hospital
readmissions have been singled out for
improvement by CMS National Strategy by
Quality Improvement in Health Care. The goal of
the CMS strategy is a 20% reduction in hospital
readmission rates by end of 2013, potentially
preventing 1.6 million hospitalizations and saving
an estimated 15 billion dollars. Combining
financial incentives and penalties the Affordable
Care Act (ACA) seeks to promote coordination
across the continuum of care. The Hospital
Readmission Reduction Program (HRRP) is
32 LUNG HEALTH PROFESSIONAL MAGAZINE • VOLUME 3 I NUMBER 1 I 2012
designed to reduce all cause readmissions by
aligning payments to outcomes. The outcome
measurement proposed is hospital specific, risk
stratified all cause 30 day excess readmission
ratio following index admission for acute
myocardial infarction, congestive heart failure,
or pneumonia. Underperforming hospitals will
incur a reduction of Medicare based
reimbursements for inpatient services starting
fiscal year 2013 and increasing over the next
several years. In addition, HRRP will require
expansion of public reporting and will
supplement the initial three readmission
measures. COPD exacerbation hospitalizations
are a likely target.
In 2003-2004 the 30-day readmission rate
among patients hospitalized with COPD was
22.6%, accounting for 4% of all 30-day
readmissions. In 2007, the Medicare Payment
Advisory Council listed COPD as number four of
the seven conditions associated with the most
costly potentially preventable readmissions.
Recently released data from 2008 across 15
states and over 190,000 index COPD admissions
documented a 20.5% 30-day all cause
readmission rate. Costs were consistently higher
for readmissions than for the index
hospitalizations.
Dr. Thomashow reviewed data from a chart
review of COPD admissions in 2005-2006 in 5
city hospitals and 4 community hospitals in the
New York-Presbyterian Healthcare System (Yip
et al JCOPD 2010;7;85-92) This study, which
reviewed over 2000 COPD hospitalizations,
suggested that while in-hospital care generally
followed suggested guidelines with
combination of systemic steroids, antibiotics,
and bronchodilators, most patients were not
receiving the suggested maintenance regimens.
Dr Thomashow also reviewed a recent article in
Thorax (Hopkinson et al Thorax
10.1136/thoraxjnl-2011-200233) which described
a discharge bundle. This bundle consisted of
smoking cessation assistance for active
smokers, assessment for pulmonary
rehabilitation, a written COPD patient
information plan, teaching of appropriate
inhaler use, arranging a phone call check within
48-72 hours of discharge, and setting up an
outpatient appointment shortly post discharge.
Dr. Thomashow stressed that his institution and
others are working on similar discharge plans.
He also emphasized that the financial incentives
and penalties that are being put into effect
should allow hospitals and institutions to
partner with physicians and patient groups so
as to develop better care plans for COPD.
Dr. Casaburi reviewed a recent meta-analysis
from the Cochrane Database. The paper
looked at the effect of pulmonary
rehabilitation after COPD exacerbation on rehospitalization and included five studies
involving 250 subjects with follow up ranging
from 12 to 76 weeks. Research showed that
pulmonary rehabilitation significantly
decreased readmission rates. Three studies,
involving 110 subjects, looked at the effect of
rehabilitation on mortality, and here too
pulmonary rehabilitation appeared to have real
benefit. Dr. Casaburi stressed that these studies
had limitations including small sample sizes in
individual studies, the analysis being based on a
small number of events, the impossibility of
blinding the intervention, dissimilarities among
programs and follow-up, and the possibility of
publication bias. Having said that, these initial
results are extremely impressive. If ongoing
studies confirm these preliminary results, all
centers will need to consider post COPD
hospitalization pulmonary rehabilitation as a
possible option to improve care and decrease
readmissions.
Dr. Ohar and Dr. Kahan reviewed their
experiences regarding the readmission issue. Dr.
Ohar emphasized the importance of comorbidities adding to the complexity of COPD
hospitalizations quoting data, which shows a
40% incidence of hypertension, a 22%
incidence of diabetes, and an 18% incidence of
fluid and electrolyte disturbances. She also
presented data suggesting impressive increased
risk of cardiovascular complications post COPD
exacerbations, ranging from a risk ratio of 2.76
for heart failure to 4.37 for atrial
fibrillation/flutter, to 4.34 for ventricular
arrhythmias, and 15.6 for renal failure. She
stressed the potential impact of a selfmanagement program including a single 1-1.5
hour education session, an action plan for selftreatment of exacerbations, monthly nurse
follow-up calls and a 24-hour nurse hotline.
She reviewed data suggesting that this type of
self-management program could decrease
emergency room visits, hospital readmissions,
and cost. Dr. Ohar also reviewed her institutions
experience with pneumonias, another core
measure monitored by CMS. She described a 6
step discharge plan used for pneumonias that
could potentially be adapted for COPD use. This
plan includes a phone call to patient within first
24 hours of discharge, a visiting nurse visit
within 1-3 days, a 30 day supply of all
medications at discharge, a follow-up clinic visit
within 7 days, transportation provided for the
clinic visit if needed and a palliative care consult
in hospital if the Charlson score which estimates
mortalities were significantly elevated.
Dr. Conard reviewed the experience of his
group in Texas. He described the basis of
establishing a successful patient centered
medical home dependent upon access,
communication, patient tracking and registry,
care management, patient self-management
support, electronic prescribing, test tracking,
referral tracking, performance reporting and
improvement. He stressed that advanced
electronic communication systems were a
critical component allowing management of
over 2.4 million active patients, merging data
from 64 electronic medical servers daily, and
processing hundreds of millions of diagnoses,
procedures, lab results, medications, vital signs,
and other key clinical indicators. He described
their patient medical home summary which
included not only patient demographics,
diagnoses, vital signs, medications, lab results
and procedure history but also a list of all other
healthcare providers the patient had seen,
protocol recommendations, and patient goals.
He also described individualized clinician
dashboards depicting how the provider was
performing regarding cardiac care, diabetes
care, preventative care including vaccinations
and provided an ongoing feedback regarding
patient satisfaction. Dr. Conard pointed out the
importance of external quality recognitions,
peer comparisons, and care analysis. He
described an appointment reminder program,
which contacted all patients 24-48 hours prior
to scheduled appointments to confirm and a
chronic notification program that automatically
reached out to patients if they appear to be out
of compliance with evidence based guidelines.
Besides the importance of a robust electronic
network, Dr. Conard stressed that this process
only works with a team approach increasing the
input and value of every team member. In this
scenario the physician tasks include reviewing
data provided by the team, assessing the
patient and providing clinical management
33
continued from page 33
recommendations according to approved
guidelines. The nurse practitioner or physician
assistant tasks include dealing with acute visits,
seeing patients on alternate chronic disease
visits, and coordinating care for high acuity
patients. The RN, LPN, Medical Assistant tasks
include medication reconciliation on all patients,
working with the patient on adherence.
compliance issues, and care management. In
this system, the patient too has tasks including
defining their own goals in discussion with the
team, keeping a current medication list,
updating their medical information, and
participating in visit planning.
Dr. Conard closed by describing a patient care
pathway, that maps the patient experience
through this new and evolving healthcare
system. He felt that this type of core
coordination carried tremendous impact
reducing emergency room visits, hospital
admission and readmission rates, and overall
reducing healthcare costs while increasing
reimbursement for primary care physicians, thus
improving satisfaction of physicians, non
physician team members, and patients.
COPD7usa received unrestricted educational grants from
Boehringer Ingelheim Pharmaceuticals, CSL Behring, Forest
Laboratories, Inc, Grifols, and Pfizer Pharmaceuticals.
Author disclosures and audio of the COPD7usa sessions are
available on the COPD7usa conference website:
www.copdconferencesusa.org.
Presenters:
Dr. Jerry Krishnan:
1. Thorpe KE, CMAJ, 2009.
2. Halpin D, Prim Care Resp J 2010.
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4. US Recovery Act Spend Plan, Office of the Secretary, DHHS, 11/09
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6. Thorpe KE, CMAJ, 2009.
7. Rothwell PM. Lancet 2005; 365: 82–93.
Dr. Joe Selby
Source: Affordable Care Act. Subtitle D—Patient-Centered Outcomes Research.
PUBLIC LAW 111–148—MAR. 23, 2010.
Dr. Tony Punturieri
1. IOM Report 2009.
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3. ALLHAT Officers. JAMA 2002;288:2981-7.
4. http://www.iom.edu/CMS/3809/63608/71025.aspx
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6. National Emphysema Treatment Trial Research Group. N Engl J Med. 2003;348:2059-73.
Dr. Robert Sandhaus
1. www.alphanet.org
Dr. Tangita Daramola
1. www.cms.gov/dmeposcompetitivebid
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7. www.medicare.gov/contacts/search-results.aspx?customresult=AllSHIP
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Dr. Scott Berkowitz
1. “The Cost Conundrum” by Atul Gawande (New Yorker, 2009)
N Engl J Med 2011; 364:e12. Feb 17, 2011.
Dr. Byron Thomashow
1. Yip et al JCOPD 2010;7;85-92, Hopkinson et al Thorax 10.1136/thoraxjnl-2011- 200233.
Dr. Richard Casaburi
1. Pulmonary Rehabilitation Following Exacerbations of Chronic Obstructive Pulmonary Disease.
Puhan MA, Gimeno-Santos E, Scharplatz M, Troosters T, Walters EH, Steurer J. Cochrane Database
Syst Rev. Oct 5, 2011.
Dr. Jill Ohar
1. Coventry, PA. BMC Pulm Med 2011.
2. Khawaja FJ, Arch Int Med 2011.
3. Lindenauer PK Annals of Int Med 2006 p896.
4. Tashkin-ERS poster 2010.
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8. Borbeau J CHEST 2010.
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10. Mannino DM, Respir Med. (2009) p224.
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atient_Action_Plan_fpr_COPD_signs_and_symptoms.pdf. Accessed September 2010.
Dr. Scott Conard
1. National High Blood Pressure Education Program (NHBPEP)/National Heart, Lung, and Blood
Institute (NHLBI) and American Heart Association (AHA) working meeting on blood pressure
measurement. Summary report. Bethesda, MD: National Institutes of Health; April 19, 2002.
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Services, National Institutes of Health, National Heart, Lung, and Blood Institute; August 2004.
NIH Publication No. 04-5230.
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